ABSTRACT
BACKGROUND: EUS-guided biliary drainage (BD) is an evolving alternative technique for patients with malignant biliary obstruction for which ERCP failed. OBJECTIVE: To compare the outcomes of 2 nonanatomic EUS-guided BD routes: hepaticogastrostomy (HPG) and choledochoduodenostomy (CD). DESIGN: Prospective, randomized trial. SETTING: Tertiary endoscopic referral center. PATIENTS: Forty-nine patients with unresectable distal malignant biliary obstruction and failed ERCP were included. The HPG group had 25 patients and the CD group had 24 patients. INTERVENTIONS: EUS-guided HPG or CD. In all procedures, a biliary puncture with a 19-gauge needle followed by cholangiography, wire advancement, track dilation, and self-expandable metal stent deployment were performed. MAIN OUTCOME MEASUREMENTS: Technical and clinical success, quality of life, adverse events, and survival. RESULTS: The technical success rate was 96% for HPG and 91% for CD. The clinical success rate was 91% for HPG and 77% for CD. The mean procedural time was 47.8 minutes for HPG and 48.8 minutes for CD. The mean scores of quality of life were similar during follow-up. The overall adverse event rate was 16.3% (20% for the HPG group and 12.5% for the CD group). One patient with a bile leak required percutaneous biloma drainage. There was no statistical difference between the 2 techniques and no difference with regard to survival time between the 2 groups. LIMITATIONS: Single-center study. CONCLUSION: HPG and CD techniques are similar in efficacy and safety. Both HPG and CD seem valid alternative options for BD in patients with distal malignant biliary obstruction after failed ERCP.
Subject(s)
Choledochostomy , Cholestasis/surgery , Hepatic Duct, Common/surgery , Jaundice, Obstructive/surgery , Neoplasms/complications , Stomach/surgery , Adult , Aged , Aged, 80 and over , Anastomosis, Surgical/adverse effects , Anastomosis, Surgical/methods , Cholangiopancreatography, Endoscopic Retrograde , Choledochostomy/adverse effects , Cholestasis/etiology , Drainage/methods , Endosonography , Female , Follow-Up Studies , Humans , Jaundice, Obstructive/etiology , Male , Middle Aged , Neoplasms/pathology , Prospective Studies , Quality of Life , Self Expandable Metallic Stents , Survival Rate , Treatment Failure , Ultrasonography, InterventionalABSTRACT
Objectives. Endoscopic management of bile leak after orthotopic liver transplant (OLT) is widely accepted. Preliminary studies demonstrated encouraging results for covered self-expandable metal stents (CSEMS) in complex bile leaks. Methods. Thirty-one patients with post-OLT bile leaks underwent endoscopic temporary placement of CSEMS (3 partially CSEMS , 18 fully CSEMS with fins and 10 fully CSEMS with flare ends) between December 2003 and December 2010. Long-term clinical success and safety were evaluated. Results. Median stent indwelling and follow-up were 89 and 1,353 days for PCSEMS, 102 and 849 for FCSEMS with fins and 98 and 203 for FCSEMS with flare ends. Clinical success was achieved in 100%, 77.8%, and 70%, respectively. Postplacement complications: cholangitis (1) and proximal migration (1), both in the FCSEMS with fins. Postremoval complications were biliary strictures requiring drainage: PCSEMS (1), FCSEMS with fins (6) and with flare ends (1). There was no significant differences in the FCSEMS groups regarding clinical success, age, gender, leak location, previous treatment, stent indwelling, and complications. Conclusion. Temporary placement of CSEMS is effective to treat post-OLT biliary leaks. However, a high number of post removal biliary strictures occurred especially in the FCSEMS with fins. CSEMS cannot be recommended in this patient population.